Inspection on 21/06/05 for Tanfield Care Centre

This inspection was carried out on 21st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Tanfield Care Centre 30/05/07

Tanfield Care Centre 06/12/05

Tanfield Care Centre 21/07/04

Tanfield Care Centre 20/01/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE TANFIELD CARE CENTRE 2 Hexham Road Northumberland Avenue Reading Berks Lead Inspector Robert Dawes Unannounced 21 June 2005, 11.15 am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Tanfield Care Centre Address 2 Hexham Road, Northumberland Avenue, Reading, Berks Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0118 9674675 Reading Borough Council Care Home (CRH) 31 Category(ies) of Old age, not falling within any other category registration, with number (OP) 23 of places Dementia - over 65 years of age (DE(E)) 8 Physicla disability (PD) 12 TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No service user to be admitted under the age of 60 years of age Date of last inspection Brief Description of the Service: Tanfield Care Centre is a Reading Borough Council care home. It is purpose built and situated in Whitley, a suburb of Reading. The home will eventually provide personal care and accommodation for thirty one service users, of whom twelve will be accommodated in the Intermediate Care unit, eight in the E.M.I. unit (including one respite), and eleven in the Assessment and Intervention unit. The home currently accommodates three long stay service users, eight in the Intermediate Care unit, 8 in the EMI unit and four in the Assessment and Intervention unit. The home is equipped with a passenger lift and aids and equipment to assist the more dependent service users. Thirteen of the bedrooms have en-suite facilities. The aim of the home is to provide a homely and comfortable atmosphere; a lifestyle that satisfies their social, cultural, religious and recreational interests and needs; promote and maintain service users’ health; and to ensure the independence and individuality of the service users is respected. An occupational therapist, physiotherapist and a rehabilitation manager have been employed by the Health Authority to work in the Intermediate Care unit alongside local authority care workers. TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection, which was carried out between 11.15am and 4.05pm on Tuesday 21st June 2005. The Inspector spoke with the manager, deputy manager, a member of staff, and two service users. The Inspector also saw records and toured the premises. Fourteen standards were assessed of which thirteen were met and one was nearly met. One requirement and one recommendation were made during this inspection. One requirement was carried forward from the previous inspection because it could not be assessed. What the service does well: What has improved since the last inspection? Significant improvement has been made to the physical condition of the home. The home’s security has been improved with the introduction of outside CCTV cameras and keypads to exit the building. The recruitment and retention of care staff has improved resulting in more positive teamwork being developed. TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 6. New service users are admitted only on the basis of a full assessment. Where service users are admitted only for intermediate care, dedicated accommodation is provided, together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. EVIDENCE: The nurse coordinator undertakes the assessments for admissions to the intermediate care unit and the assessment and intervention unit. The home’s management team then ratifies these assessments. The manager and deputy manager undertake the assessments for service users applying for the dementia unit. A service user who was recently admitted to the assessment and intervention unit is exhibiting behaviour which is very upsetting to other service users. Her needs are primarily mental health and the Inspector questioned whether the home is meeting this person’s needs. The manager is going to review the service users placement. The Inspector recommended the criteria for TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 9 admission to the assessment and intervention unit is clear in relation to mental health service users and does not allow for inappropriate admissions. A full time nurse coordinator, a part time physiotherapist, two part time occupational therapists and an assistant occupational therapist are employed by the Health Authority to work in the intermediate care unit alongside appropriately trained care assistants. Dedicated accommodation is provided, together with specialised facilities and equipment. TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 9. All service users have an individual care plan. Service users are able to take responsibility for their own medication if they wish. Staff adhere to the procedures for the receipt, storage, handling, administration and disposal of medicines. Staff are not adhering to the procedures for recording the administration of PRN medication. EVIDENCE: Every service user has an individual plan. The plans for service users in the intermediate care unit and the assessment and intervention unit are reviewed every week. For service users in the dementia and long stay units their plans are reviewed monthly. Reviews with relatives take place at regular intervals. The self-medication policy and procedures are almost complete. Service users who self medicate have lockable cabinets in their rooms to keep their medicines. The pharmacist visits regularly to inspect the receipt, recording, storage, handling, administration and disposal of medicines. The pharmacist’s report showed that at her last two visits gaps were found in the medication records. The Inspector also found gaps in the records for PRN administration. TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) This section was not assessed. EVIDENCE: TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The home has a complaints procedure. Service users and their relatives know how to make a complaint. The home has procedures for responding to suspicion or evidence of abuse. Staff receive training in identifying and responding to incidents of abuse. EVIDENCE: The home has a complaints procedure. Leaflets on how to make a complaint are given to service users and their relatives. No complaints have been made against the home since the last inspection. The manager encourages service users to voice their wishes and feelings. The home has a vulnerable adults procedure (including whistle blowing). Vulnerable adults training is taking place for all staff. The accidents to service users is monitored on a monthly basis. TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26. Service users live in a safe, well-maintained and comfortable environment. The home is clean, pleasant and hygienic. EVIDENCE: The location and layout of the home is suitable for its stated purpose; it is safe and generally well maintained; and in recent months has been significantly improved through new downstairs carpets being fitted, new windows being installed, a new entrance being built and new perimeter fencing erected. The security of the premises has been improved with the installation of outside CCTV cameras and a keypad to exit the home. Kitchens in the intermediate care area are due to be refurbished and the manager has identified areas of the home that needs decorating. The home was clean and hygienic. TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, and 30. Service users needs are met by the numbers and skill mix of the staff. The manager must ensure 50 of the care staff achieve NVQ2 or above in care as soon as possible. Staff are provided with a comprehensive training programme which provides them with the knowledge and skills to undertake their jobs. EVIDENCE: The ratio of staff to service users is satisfactory. Two staff are on duty for the intermediate care unit, two for the dementia unit and two for the long stay and assessment and intervention unit. At night there are two waking staff on duty with a member of staff ‘sleeping in’ as back up. Some staff only work on a specific unit while others rotate between them. The home also employs domestics, cooks, a maintenance man and an activity coordinator. Since the last inspection the number of vacant hours has been significantly reduced and the manager is confident that within a few weeks the home will have a full compliment of staff. Staff undertaking overtime and regular agency staff has covered the vacant care hours. Staff were observed to treat staff patiently and respectfully. A service user informed the Inspector that staff were very caring and responsive. She also said staff regularly check her at night. Seven staff other than the manager and deputy have a NVQ 2 or above in care. Now new staff have been recruited and the team is more stable the TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 15 manager will ensure as many staff as possible achieve the required qualifications. The requirement made at the last inspection relating to the recruitment standard could not be assessed as the recruitment files are kept at the Human Resources Dept. of Reading Borough Council. All new staff undertake the Induction and Foundation training programmes and within six to twelve months will also have completed training on key aspects of their responsibilities such as fire safety, food hygiene and manual handling. Reading Borough Council also provides a comprehensive range of courses covering topics such as dementia, incontinence and medication. TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 and 38. Effective quality assurance and quality monitoring systems are in place. Service users’ financial interests are safeguarded. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: Feedback is actively sought from service users about services provided through day-to-day contact. The relatives of long term service users and service users in the EMI unit are sent satisfaction questionnaires before reviews. Every intermediate care service user is asked to complete a satisfaction questionnaire when leaving the home. The selection of the returned questionnaires read by the Inspector was very positive. The manager will be producing an annual development plan. TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 17 The manager is not the appointee for any service user. Service users’ personal money is kept in individual accounts. Records and receipts are kept of all transactions and regular audits take place. Secure facilities are provided for the safekeeping of money on behalf of service users. The health and safety records seen by the Inspector showed the proprietor/manager ensures so far is reasonably practicable that service users are protected. TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 3 TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13 Requirement Staff must adhere to the procedures for recording the administration of medication. Timescale for action Immediatel y. 2. 29 17 A copy of birth certificates and 31/8/2005. passports must be kept on all persons working in the home.(This requirement was made at the previous inspection but could not be assessed on this visit). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 1015 Arlington Business Park Theale Berks RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI TANFIELD CARE CENTRE H51-H01-S39942-Tanfield Care Centre-V230832210605-Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!